83 Concomitance of primary systemic lupus erythematosus and Wilson’s disease in a male child: a case report

Background

Wilson’s disease (WD) is a rare, recessively inherited disorder of copper metabolism with its accumulation in multiple organs particularly in the liver and brain. Systematic lupus erythematosus (SLE) is an autoimmune disease like Wilson’s disease, involves multiple organs and systems. The combination of Wilson's disease and systemic lupus erythematosus (SLE) is not usual apart from iatrogenism.

Objectives

we present a pediatric case of concurrent Wilson’s disease and primary SLE not induced by penicillamine. After extensive research in the literature, this is the only male case described so far. The other seven cases reported are female.

Case presentation

A previously well 12-year-old boy was admitted to University Hospital Center of Batna (Algeria) with acute haemolysis (pallor, subictereus, and red urine). There was no consanguinity, or family history of note. Physical examination revealed normal development and growth, no fever, no lymphadenopathy, no hepatomegaly and splenomegaly. A complete blood count (CBC) revealed normochromic normocytic anaemia, thrombocytopenia, and leucopenia. His blood biochemistry showed hepatic cytolysis, and hepato-cellular insufficiency. Wilson’s disease was suspected because of the combination of the impaired liver function, hemolytic anaemia, and normal alkaline phosphatase levels. Serum ceruloplasmin and copper levels were decreased, while urinary copper was elevated confirming the diagnosis of Wilson’s disease. There was no neurological or ophthalmologic involvement. Family investigation revealed Wilson's disease with cirrhosis in a 9-year-old brother.

The onset of nephrotic syndrome and the presence of inflammatory syndrome cannot be explained by Wilson’s disease. The kidney biopsy histopathology revealed nephritis lupus class II (WHO classification). Subsequent serum analysis also revealed positive native anti-DNA and anti-PCNA antibodies verified on a second sample. Based on all the findings, the final diagnosis for this patient was Wilson’s disease combined with SLE. We started therapy with bolus of corticosteroids and Cyclophosphamide, relayed by Mycophenolate Moftil and hydroxychloroquine Cooper chelation has also been initiated.

Improvement in renal and even hepatic damage was noted. Unfortunately, after two years, the patient presented abnormal movements with dysarthria. Brain MRI showed abnormal signals of the basal ganglia consistent with neurological damage in Wilson's disease.

Discussion

concomitant SLE and WD without penicillamine treatment is rare (7 cases reported in the literature with 3 children). To our knowledge, this is the first report of an association between Wilson's disease and SLE in male case. For our patient, SLE and Wilson’s disease were diagnosed simultaneously as 4 described cases.

Wilson’s disease was first suspected due to unexplained impaired liver function with hemolytic anaemia. Copper Tests confirming the diagnosis. At that time, there was no neurological or ophthalmological impairment.

For this patient, the worsening of the hematological involvement (pancytopenia) in an inflammatory context, with installation of a nephrotic syndrome cannot be explained by Wilson's disease. SLE was evoked despite the fact that it was a child and male. The PBR as well as the immunological workup were in favor of SLE disease.

Treatment of SLE improved symptoms but later chelation could not prevent the usual neurologic complication of Wilson’s disease at this age. The neurological involvement appeared at the age of 14 as described in the literature with the common sign dysathria, followed by the installation of abnormal movements due to the impairment of the basal ganglia objectived by MRI.

Conclusion

Wilson’s disease and SLE not induced by penicillamine can co-exist. As there is no pathophysiological explanation, it’s probably a simple fortuitous association.

54 Kawasaki disease: experience in a general paediatric department of the CHU de Annaba Algeria

Background

Kawasaki disease (adeno-cutaneous-mucosal syndrome) is an acute febrile systemic vasculitis, affecting with predilection infants. Of unknown aetiology, its diagnosis is based on clinical criteria validated by the CDC and updated by the American Heart Association. Its prognosis is linked to the presence of coronary complications. Its prevalence in Algeria remains unknown, the increase in the number of cases in recent years has raised questions about its situation in our department.

Objective

To study the epidemiological, diagnostic, therapeutic, biological and evolutionary aspects of this disease.

Materials and methods

The authors report the results of a retrospective study of 2 years and 4 months, concerning 15 cases of Kawasaki disease hospitalized and treated in the pediatric department of the University Hospital of Annaba. The information was obtained from the hospitalization records.

Results

15 cases of Kawasaki disease were identified during the study period. Almost half of the patients were between 2 and 5 years of age, with an average age of 26.3 months (range: 11 months-9 years). A clear male predominance was noted (SR: 2). The reasons for hospitalization were dominated by fever (73%), skin involvement (66%) and stomatitis (40%). The clinical examination showed the frequency of the classical criteria of the disease with almost constant fever (100%), polymorphous skin rash 93.33%, oral-pharyngeal involvement 93.33%, involvement of hands and feet 40%, conjunctivitis 53.33% and adenopathies 46.67%. Biologically, the blood count showed anaemia (93.33%), hyperleukocytosis (66.67%) and hyperplateletosis (46.67%); an accelerated blood count in all our patients and an elevated CRP in 86.67% of cases. Doppler ultrasound performed in all patients returned normal in 73.33% of cases and found 2 cases of mitral insufficiency and 1 case of 8 mm coronary aneurysm. All our patients were treated with human immunoglobulins (2 g/kg IV) associated with aspirin 80–100 mg/kg/d in 4 doses. The evolution was favorable for all our patients.

Conclusion

Kawasaki disease is a pediatric vasculitis whose severity is related to coronary complications, which are prevented by early administration of IG and aspirin. It is therefore imperative to think of the disease in front of a prolonged fever associated with cutaneous and mucosal clinical signs and a biological inflammatory syndrome.

Inborn Errors of Immunity in Algerian Children and Adults: A Single-Center Experience Over a Period of 13 Years (2008–2021)

Background

Inborn errors of immunity (IEI) predispose patients to various infectious and non-infectious complications. Thanks to the development and expanding use of flow cytometry and increased awareness, the diagnostic rate of IEI has markedly increased in Algeria the last decade.

Aim

This study aimed to describe a large cohort of Algerian patients with probable IEI and to determine their clinical characteristics and outcomes.

Methods

We collected and analyzed retrospectively the demographic data, clinical manifestations, immunologic, genetic data, and outcome of Algerian IEI patients - diagnosed in the department of medical immunology of Beni Messous university hospital center, Algiers, from 2008 to 2021.

Results

Eight hundred and seven patients with IEI (482 males and 325 females) were enrolled, 9.7% of whom were adults. Consanguinity was reported in 50.3% of the cases and a positive family history in 32.34%. The medium age at disease onset was 8 months and at diagnosis was 36 months. The median delay in diagnosis was 16 months. Combined immunodeficiencies were the most frequent (33.8%), followed by antibody deficiencies (24.5%) and well-defined syndromes with immunodeficiency (24%). Among 287 patients tested for genetic disorders, 129 patients carried pathogenic mutations; 102 having biallelic variants mostly in a homozygous state (autosomal recessive disorders). The highest mortality rate was observed in patients with combined immunodeficiency (70.1%), especially in patients with severe combined immunodeficiency (SCID), Omenn syndrome, or Major Histocompatibility Complex (MHC) class II deficiency.

Conclusion

The spectrum of IEI in Algeria is similar to that seen in most countries of the Middle East and North Africa (MENA) region, notably regarding the frequency of autosomal recessive and/or combined immunodeficiencies.

P093 Algodystrophy in children: a case report

Background

Algodystrophy is an entity very often unrecognized by pediatricians. The evolution is readily dragging and disabling in the absence of early and coordinated care. The Objective: Based on a case observed in a 10-year-old boy, the authors recall the main characteristics of the syndrome, guiding the practitioner to make the diagnosis, and implement appropriate and early therapy.

Observation

A 10-year-old boy with no previous medical history, presenting with neuropathic-like pain in the wrist and the hand that started a month ago without any triggers. Clinical exam noted functional impotence, a whole limb tremor, hyperesthesia as well as allodynia.

The patient's hand is swollen and warm with a claw-like appearance.

The rest of the body exam is normal.

The laboratory markers and x-rays of the whole limb are normal. Bone scintigraphy confirms the diagnosis of wrist algodystrophy. The treatment combining corticosteroids, functional rehabilitation, and psychotherapy allowed a favorable outcome with no sequelae.

Conclusion

The diagnosis of algodystrophy remains too often unrecognized, and its management is sometimes inadequate. Early diagnosis and treatment improve the prognosis.

P064 Henoch-Schonlein Purpura: experience of a general pediatric center

Background

Henoch-Schonlein purpura (HSP) is the most classic dysimmune vasculitis in children, related to an abnormal response of an immature immune system following an external antigen attack. Digestive involvement in HSP conditions the immediate vital prognosis and severe renal failure conditions the long-term functional prognosis. The Objective is to identify the epidemiological, clinical, disease course and therapeutic particularities of patients with HSP with a review of the literature.

Material and method

The authors reported the results of a retrospective study of cases of patients with HSP hospitalized and treated in the 02 pediatric departments of the wilaya of Annaba in Algeria (Clinique Sainte Thérèse, Annaba hospital university center and EHS El Bouni) over a period of 02 years. Information was obtained from hospital records.

Results

24 cases of HSP were identified with a sex ratio of 1.4 (14 boys and 10 girls) and a hospital incidence of 1.66%. The average age was 6.6 years. Half of patients was hospitalized during the autumn-winter period, 67% of whom had an ENT infection before their hospitalizations. 17% of cases have personal history of HSP (the oldest was 5 years ago and the most recent 10 days before hospitalization). 7 patients underwent surgeries prior to hospitalization. Skin lesions were found in all patients. Joint, digestive and renal involvement were recorded in 50%, 80% and 25% respectively. Gastrointestinal bleeding has been observed in one patient. Only 1 patient with renal impairment progressed to chronic renal failure and only 1 patient had confirmed hypertension. A rare association with viral hepatitis A has been noted in one patient.

Conclusion

HSP remains a benign condition, easy to recognize clinically. Its immediate prognosis depends on the digestive complications and its long-term on nephropathy which may expose to the risk of chronic renal failure.

P056 Acute rheumatic fever: still a hot topic

Background

Acute rheumatic fever (ARF) still a very common condition and constitutes a real public health problem in the developing countries including Algeria. The objective is to assess the epidemiological and clinical profile and the disease course of ARF in our region and estimate the incidence of cardiac complications.

Method

The authors report the results of a retrospective study of 52 cases of ARF in children, hospitalized and treated at the Sainte Therese Clinic of the CHU Annaba for a period of 6 years. The diagnosis was made according to Jones criteria. Information was obtained from hospital records.

Results

The disease mainly concerned the age group of 4–10 years (52%), the sex ratio was 0.86 (28 girls, and 24 boys). The maximum number of hospitalizations is observed during the rainfall period (October-March). 54% of patients had untreated angina. Clinically, fever was noted in 23 patients, polyarthritis in third of cases and a heart murmur in half of patients. Doppler-coupled echocardiography founded carditis in 73% of patients: Endocarditis was noted in all of these cases and the mitral insufficiency was the dominant anatomo-clinical form. The number of infra-clinical carditis was considerable (10/38 cases of carditis). Biologically, accelerated ESR (> 50 mm/H1) was observed in 65% of cases, high CRP level and hyper leucocytosis were noted in 38 and 31 patients, respectively. ASLOs were high in 85% of cases. The outcomes were favorable in the majority of cases. Nevertheless 5 relapses were recorded, including 3 complicated by severe carditis.

Conclusion

ARF still frequent in our region. Cardiac complications are always frequent and constitute a major factor of morbidity. Our results illustrate the absolute need for a rigorous application of the national prevention program, the main objective of which is to reduce the prevalence of rheumatic heart disease.

Survival Childhood Cancer in a Paediatric Ward

Background: In the world the overall ASR childhood cancer was 141 per million at age 0-14 years. In Algeria the ASR is 96.3 per million [IICC-3] and the rate of paediatric neoplasm among overall cancers was approximately 3%. There is a lack of data on survival childhood cancer. Aim: Describe the survival of 0-14 years old children diagnosed with a cancer in the pediatric ward of University Hospital (UHA). Methods: All cancer cases admitted in pediatric ward of University Hospital of Annaba, in the period between 2014 and 2017 were included. The tumors were classified according to the third edition of the International Classification of Childhood Cancer (ICCC-3). Survival overall and specific rates (according cancer group and age groups) were calculated using Kaplan-Meier method. Results: Among 272 cancer cases included, 56% were boys and 44% were girls. The main cancer groups were: leukemia (36.8%), lymphoma (14.7%), central nervous system tumors (13.6%), nephroblastoma (11.8%), bone tumors (5.9%), sympathetic nervous system tumors (5.1%), soft-tissue sarcomas (5.1%) and others 6.0%. The median survival of overall cancers was 2.7 ± 0.5 years. According the sex, it was 2.7 ± 0.5 years for girls and 2.3 ± 0.6 years for boys ( P > 0.05). According age groups: the median survival was better for children aging more 2 years old (3.0 ± 0.5 years) compared with children less than 2 years old (1.4 ± 0.6 years) and P < 0.05. The median survival of leukemia was 3.0 ± 0.6 years, of lymphoma was 5.9 ± 0.00 years and 1.8 ± 0.0 years for central nervous system tumors. For nephroblastoma 56.7% of cases were in live until 2 years. Conclusion: More efforts must be made to improve medical care and survival childhood cancer.

Prevalence rate of exercise-induced bronchoconstriction in Annaba (Algeria) schoolchildren

BACKGROUND

We studied the prevalence rate of exercise-induced bronchoconstriction (EIB) in Annaba schoolchildren. No previous assessment of this syndrome had ever been done in Algeria.

METHODS

EIB was evaluated using the 6 min free running test (6MFRT) on 286 children, 87.4% of whom were 10-12 years old. They performed the test in the morning, during the autumn-winter season. Peak expiratory flow rate (PEFR) was measured before, and then 5 and 10 min after the 6MFRT, a 15% or more decrease in post-exercise PEFR being defined as significant.

RESULTS

EIB was much more frequent in asthmatic than in nonasthmatic children (47.0% vs. 13.9%, p < .001) and the drop in PEFR was more marked among the former. EIB was observed more often in a cool temperature (<8°C). There were relatively more children who were either eutrophic or overweight among those presenting an EIB. Past histories of nocturnal wheezing and rhinoconjunctivitis presented respectively the best specificity (96.7%) and sensitivity (84.8%). Children of unemployed workers presented the highest occurrence of EIB. Passive smoking appeared as the only factor being related to EIB among the indoor pollutants. The prevalence rate of asthma (6.7%) was higher than in a previous cross-sectional epidemiological survey study performed in the Maghreb. The prevalence rate of EIB (13.9%) was situated in the upper range of the results given worldwide.

CONCLUSIONS

These features of a fairly high bronchial hyperresponsiveness could be facilitated by the polluted environment of the city.